Repetitive Self-injurious Behavior Research Articles

22.3 SELF-INJURIOUS BEHAVIOR IN CATATONIA IN AUTISM SPECTRUM DISORDER: POINTERS, PEARLS, AND CHALLENGES

The objectives of this presentation are to provide an overview of the current understanding regarding repetitive self-injurious behavior as a symptom of catatonia in autism spectrum disorder (ASD), the paradigms and lessons learned, as well as longstanding and novel challenges. The literature review and direct clinical experience will be discussed. Catatonia is reported to occur in 12% to 20% of youth with ASD, with significant advances in understanding over the past 2 decades. Some youth with ASD experience more “expected” psychomotor-retarded catatonic symptoms, such as slowness, rigidity, getting “stuck,” and posturing, speech abnormalities, or frank mutism, which are often coupled with prominent skill regression. This presentation can lead to massive clinical devastation, as is also the case when psychomotor agitation dominates the catatonic picture, often in the form of intractable self-injury devoid of any operant function, unresponsive to any behavioral intervention, and often requiring the most desperate measures of bodily restraint to prevent catastrophic tissue damage. Three current cases will be reviewed describing catatonia in ASD, where life-threatening self-injurious behavior (SIB) dominated the catatonic clinical picture. One youth had experienced prior catatonic episodes resulting in severe malnutrition and bilateral retinal detachment from head-directed SIB before relative stability was achieved with ECT; maintenance ECT remained de rigueur for months as this patient’s illness course waxed and waned. Another youth spent 9 months restrained in a pediatric unit in a state of chronic agitated catatonia until ECT introduction; despite massive improvement with ECT, this patient exemplified the complexity of such cases in terms of additional behavioral complexities requiring intensive management. A third youth with intractable head-directed SIB experienced prompt relief with ECT introduction; his treatment, however, was inadvertently disrupted by the COVID-19 pandemic, with many lessons learned from his brief relapse and subsequent renewed recovery. Recognition of repetitive SIBs devoid of environmental function as part of the catatonic spectrum in ASD is no longer novel. Much continues to be learned, however, about both the acute and long-term management of such patients, with pearls, new challenges, and vistas for improvement.

Treatment of Severe Self-Injurious Behavior in Autism Spectrum Disorder by Neuromodulation

An increasing number of case reports and series document the safe and effective use of electroconvulsive therapy (ECT) in children, adolescents, and young adults with autism spectrum disorder who engage in severe, intractable, repetitive self-injurious behavior (SIB) without environmental or operant function. Although the treatment is very effective for such patients, they typically remain highly dependent on frequent maintenance ECT (M-ECT) to maintain suppression of the SIB achieved during the acute course. Some patients receive M-ECT as frequently as once every 5 days. Such a regimen is quite burdensome for the patient and the patient's family, and the long-term effects of such regimens, starting as early as childhood, are unknown. In this review, we explore the expanding literature supporting the use of ECT for suppressing severe SIB associated with autism spectrum disorder. We also focus on the possible development of alternate nonconvulsive focal forms of brain stimulation, which might replace frequent M-ECT or reduce how frequently a patient needs to receive it. Although there are scarce clinical data currently available supporting these latter treatments, future studies are clearly indicated.

Non-targeted metabolomics by high resolution mass spectrometry in HPRT knockout mice

AimsLesch-Nyhan disease (LND) is characterized by hyperuricemia as well as neurological and neuropsychiatric symptoms including repetitive self-injurious behavior. Symptoms are caused by a deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT) as a result of a mutation on the X chromosome. To elucidate the pathophysiology of LND, we performed a metabolite screening for brain and serum extracts from HPRT knockout mice as an animal model for LND. Main methodsAnalyses were performed by high performance liquid chromatography (HPLC)-coupled quadrupole time-of-flight mass spectrometry (QTOF-MS). Key findingsIn brain extracts, we found six metabolites with significantly different contents in wild-type and HPRT-deficient mice. Two compounds we could identify as 5-aminoimidazole-4-carboxamide ribotide (AICAR) and 1-methylimidazole-4-acetic acid (1-MI4AA). Whereas AICAR was accumulated in brains of HPRT knockout mice, 1-MI4AA was decreased in these mice. SignificanceBoth metabolites play a role in histidine metabolism and, as a consequence, histamine metabolism. AICAR, in addition, is part of the purine metabolism. Our findings may help to better understand the mechanisms leading to the behavioral phenotype of LND.

Nonsuicidal Self-Injury among Youth

Following the 2007 definitional consensus of nonsuicidal self-injury (NSSI), there have been significant advances in our understanding of the behavior, particularly among children, adolescents, and young adults. 1 International Society for the Study of Self-injury. [homepage on the Internet]. http://www.isssweb.org. Accessed July 15, 2013. Google Scholar Given the tremendous growth of the field, in 2013 the American Psychiatric Association incorporated NSSI into their diagnostic manual as a disorder warranting further research. 2 American Psychiatric Association Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Association, Arlington (VA)2013 Crossref Google Scholar NSSI is defined as the deliberate immediate destruction of one's own body tissue (eg, self-cutting, bruising, burning) in the absence of conscious suicidal intent. This definition excludes socially accepted practices such as tattooing and body piercing. 1 International Society for the Study of Self-injury. [homepage on the Internet]. http://www.isssweb.org. Accessed July 15, 2013. Google Scholar Stereotypic and repetitive self-injurious behavior by youth with developmental disabilities and neuropsychiatric disorders as well as major forms of NSSI (eg, bone breaking, amputation) are subsumed under the broad umbrella of NSSI behaviors 3 Nock M.K. Favazza A.R. Nonsuicidal self-injury: definition and classification. in: Nock M.K. Understanding nonsuicidal self-injury: origins, assessment and treatment. American Psychological Association, Washington (DC)2009: 9-18 Crossref Google Scholar ; however, the current review focuses on NSSI that occurs in typically developing youth, which is consistent with current conceptualizations in the field. 3 Nock M.K. Favazza A.R. Nonsuicidal self-injury: definition and classification. in: Nock M.K. Understanding nonsuicidal self-injury: origins, assessment and treatment. American Psychological Association, Washington (DC)2009: 9-18 Crossref Google Scholar , 4 Klonsky E.D. Muehlenkamp J.J. Lewis S.P. Walsh B. Nonsuicidal self-injury. Hogrefe Publishers, Cambridge (MA)2011 Google Scholar , 5 Nixon M.K. Heath N.L. Self-injury in youth: the essential guide to assessment and intervention. Routledge, New York (NY)2008 Google Scholar

Alexithymia and Personality Disorders in the Adolescent Non-suicidal Self Injury: Preliminary Results

The aim of the present study was to describe the characteristics of repetitive self-injurious behaviour and related personality functioning as well as to explore the relationship between NSSI and alexithymia in a sample of NSSI adolescents (mean age= 16.1 yrs) within therapeutic communities. The results showed a representation of Cluster B personality features and personality disorders (e.g., borderline, narcissistic, antisocial). A significant association between NSSI behaviours and alexithymia was found. Additionally, the data supported the use of SWAP-200-A as an instrument for assessing personality functioning and personality pathology in adolescents who self-injure. Future research will be necessary to confirm these results.

Maintenance Electroconvulsive Therapy for Aggression and Self-Injurious Behavior in Two Adolescents With Autism and Catatonia

Frequent aggression toward others and repetitive self-injurious behaviors (SIB) can be features of catatonia in patients with autism. Similar to catatonia secondary to other etiologies, catatonia associated with autism responds well to treatment with benzodiazepines and/or electroconvulsive therapy (ECT). The authors report here on two adolescent patients with autism who presented with severe aggression, one of whom also engaged in repetitive SIB. With ongoing treatment with maintenance ECT, dramatic reduction in aggression and SIB were noted, allowing both patients a reasonable quality of life in their own homes. Attempts to taper off ECT coincided with return of aggression symptoms, although not SIB.

Assessment and Treatment of Self-Injurious Behavior Associated with Donnai-Barrow Syndrome.

Donnai and Barrow (American Journal of Medical Genetics, 68, 441-444, 1993) reported multiple participants who shared a variety of specific physical and neurological anomalies. Relatively few cases have been reported since then and few of those have progressed to an age such that the developmental progression of the disorder can be ascertained. We describe one participant with Donnai-Barrow syndrome who engaged in repetitive self-injurious behavior (SIB), which heretofore has not be described in this population. Direct observations of the participant's SIB were conducted across a range of contexts, and the behavior was successfully decreased using a combination of procedures. This case is discussed within the context of the behavioral phenotype of Donnai-Barrow syndrome.

How do researchers define self-injurious behavior?

Self-injurious behavior is commonly observed among persons with intellectual disabilities. However, a second parallel use of this term is used in the general mental health field for self-mutilation. The authors describe these two disorders and how they differ. Characteristics of what we refer to as repetitive self-injurious behavior among persons with intellectual disabilities and risk factors for these behaviors are discussed. We also describe different assessment/testing methods which aid in defining this phenomenon. The implications of these data for research and clinical practice are discussed.

S10-03 - Self-injurious behavior and suicidal behavior in adolescents: Results from population based studies in Germany

IntroductionSelf-harming and suicidal behaviour are both well-recognized problems during adolescence. While prevalence rates are very high and still rising in most western countries, there is an extensive need for understanding childhood developmental aspects, personality factors and psychological correlates of self-harm and suicidality. Additionally, specific and effective prevention should be established regarding self-harming and suicidal behaviour as one of the largest concerns of public health during this period of life.ObjectivesTo investigate the prevalence and the associated psychological and social factors of self-harming behaviour in adolescents. To evaluate a school-based intervention aimed at reducing self-harming behaviour in adolescents.MethodsIn the years 2005 and 2010 we performed one population-based, cross-sectional study including a sample of 5,759 ninth-grade students and one randomized-controlled, school-based prevention study within the large EU-consortium (SEYLE) comprising a sample-size of 1,387 students on self-harming and suicidal behaviour in Heidelberg.ResultsThe data suggest that there is a strong link between social factors and occasional self-injurious behavior and, especially in repetitive self-injurious behaviour, that there is a strong association between self-injurious behaviour and suicidal behaviour as well as self-injurious behaviour and emotional and behavioural problems. Preliminary results of the randomized-controlled prevention study could reveal a decrease of self-harming behaviour in adolescents in the short-term as well as long-term-follow-up.ConclusionsThe results support a need to investigate the possible neurobiological underpinnings as well as social factors of self-harming behaviour within a longitudinal model.

Electroconvulsive Therapy for Pediatric Malignant Catatonia With Cerebellar Dysgenesis

Electroconvulsive therapy was successfully used to treat malignant catatonia in a 15-year-old male patient with congenital dysgenesis of the left hemisphere of the cerebellum and hypoplasia of the vermis and left pons due to a presumed cerebral vascular accident in utero. The patient experienced significant motor and communication delays with mild cognitive impairment, but was otherwise in good health until age 15 years, when he developed rigidity, posturing, stupor, unresponsiveness, repetitive self-injurious behaviors, and negativism, as well as autonomic abnormalities including profuse diaphoresis and flushing episodes, thus meeting criteria for malignant catatonia. After initial response to lorazepam, the patient required electroconvulsive therapy for resolution of malignant catatonia. The case supports the safe and efficacious usage of electroconvulsive therapy for catatonia in adolescents with cerebellar and other developmental disorders. The role of the cerebellum in catatonia is also reviewed.

Electroconvulsive Therapy in a Man With Autism Experiencing Severe Depression, Catatonia, and Self-Injury

We report the successful use of electroconvulsive therapy in a 19-year-old man with autism and mild mental retardation who developed severe depression with repeated suicide attempts, multiple symptoms of catatonia, and life-threatening repetitive self-injurious behaviors. After 3 years of failed psychotropic and behavioral interventions in inpatient settings, the patient demonstrated excellent remission of symptoms with bilateral electroconvulsive therapy.

Repetitive self-injurious behavior: a neuropsychiatric perspective and review of pharmacologic treatments.

The phenomenology, pathophysiology, and psychopharmacology of repetitive self-injurious behavior (rSIB) are reviewed. Although numerous neurotransmitter systems are thought to be involved in the initiation and maintenance of rSIB, the majority of clinical studies attend to the role of serotonin or endogenous opioids. This focus has emerged from a conceptualization of rSIB as a problem of impulse control (primarily mediated by serotonin) and/or as a maladaptive pain-related behavior (ultimately mediated by opioids). A developmental perspective of rSIB is emphasized, highlighting the biased prevalence of rSIB among patients with mental retardation and severe personality disorders and the significance of critical developmental events leading to pathology in "pedagogical" neural circuits. A novel typology is offered in an effort to better match interventions with rSIB subtypes. Achievement of this ultimate goal however, must await further research.

The Use of Secure Accommodation for Adolescent Girls who Engage in Severe and Repetitive Self-Injurious Behaviour

Among the small number of girls detained in secure accommodation, severe and repetitive self-injurious behaviour (SIB) appears to be a significant problem. Effective management programmes must consider access to objects used for SIB, staff supervision, use of physical restraint and search procedures, consent to medical treatment, and effects on the peer group. Intervention programmes should be based on an analysis of the meaning and function of self-injury in individual cases, using information obtained through behavioural observation and interview. The effect on staff team behaviour and the extent to which SIB provides rewarding consequences require particular attention. Interventions to address associated emotional and psychological problems, such as the effects of childhood sexual abuse, are often not feasible within secure settings due to time factors and the reluctance of some girls to engage in therapy. Progress that is made in secure settings is often not maintained upon transfer to open settings due to insufficient service integration and a lack of time available for the generalization of behavioural change. Research is needed into outcomes and into the effectiveness of intervention programmes in secure settings. Only then will it be possible to make a realistic cost-benefit analysis of placing self injurious girls in secure settings.

Self-injurious behavior in frontotemporal dementia

Frontotemporal dementia (FTD) may be one of the most common neurodegenerative dementias with onset before age 65. Investigators have only recently characterized FTD, which encompasses Pick's disease as well as non-specific degeneration of the frontal lobes. Neuropsychiatric symptoms are the main features of FTD and include disinhibition, apathy, obsessive-compulsive behavior, and the Kluver-Bucy syndrome. We report a patient with FTD who developed prominent self-injurious behavior (SIB) consisting of persistent self-biting and hair-pulling. Stereotypical, repetitive SIB usually occurs in patients with autism or mental retardation; SIB is rarely discussed in patients with dementia. This report extends the neuropsychiatric spectrum of FTD to encompass SIB and discusses the potential mechanisms for SIB in these patients. The most likely contributing source for their self-injury is the development of obsessive-compulsive behaviors in the presence of coincident self-directed behaviors. Hyperorality from anterior temporal Involvement and the release of primitive grooming behavior from frontal degeneration are self-directed behaviors that contribute to the specific manifestations of SIB among FTD patients. The pharmacological management of SIB emphasizes drugs that work through opioid, serotonergic, or dopaminergic systems.

Naltrexone promising in repetitive self-injurious behaviour

Naltrexone promising in repetitive self-injurious behaviour